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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920216
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:33:53 PM


Document Has Been Signed on 09/24/2024 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ROSE ARBOR VILLAGEFACILITY NUMBER:
345920216
ADMINISTRATOR:EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 40DATE:
09/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Anoinette Edwards, Executive DirectorTIME COMPLETED:
04:00 PM
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On September 24, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived announced to conduct a Pre-Licensing Inspection. LPA met with Antoinette Edwards, Executive Director, who helped LPA with the inspection. This Pre-Licensing inspection is the result of a Change of Ownership.
The facility is an 2 story hotel style building that is licensed to serve (108 ) seniors. Currently, the facility has 108 rooms, a dining room, activity room, a gym, hair salon and a multi-purpose room.
LPA and the ED toured the grounds, including the dinning room multi-purpose room, offices, and visitation area. LPA observed it to be clean, safe and in good repair. LPA observed required postings, Covid posters and Emergency Disaster Plan, Resident Rights to be posted in appropriate areas. LPA observed PPE, including sanitizer to be present at the entrance of the building. There are multiple First Aid kits on site. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food.
LPA observed all fire extinguishers and smoke alarms were serviced and ready. Out of 14 fire extinguishers reviewed 4 will need servicing in the near future. The facility has Medication and charting rooms for staffs use. LPA reviewed client and staff files. Medication rooms are inaccessible to residents. Files reviewed were found to contain current documentation, including staff training.
Most residents have their meals in the dinning room. Staffing ratios were observed to be 3:1, as required, and staff have current First Aid/CPR certifications. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, and shower operate properly. Washer and dryers was present and operating properly.

To continue see 809-C...
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSE ARBOR VILLAGE
FACILITY NUMBER: 345920216
VISIT DATE: 09/24/2024
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 In December 2023, ED informed LPA that the facility has a change of ownership pending. The application has been submitted to the Department. October 1, 2024, is the estimated time the change will take effect. If and when the facility re-opens the memory care unit, LPA will go back out to inspect that section of the facility. LPA did not request updated copy of LIC308 and LIC500 due to the upcoming change. There were no deficiencies observed. Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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